UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, D.C. 20460 

Endocrine Disruptor Screening Program (EDSP) 

FFDCA §408(p) Order - SDWA §1457 Substance

OMB Control No. 

2070-0176

INITIAL RESPONSE FORM for INDIVIDUAL ORDER RECIPIENTS 

Paperwork Reduction Act Notice: The public reporting burden for this collection of information is estimated to average 1 hour per response. Send 

comments regarding the burden estimate to: Director, Collection Strategies Division (2822T), U.S. Environmental Protection Agency, Washington, DC 

20460. Do not send the completed form to this address – follow the mailing instructions in the Order and Part 4 below. 

PART 1 Recipient Information (From the Order and Completed by EPA): 

1.1. Order Info: A. Order #: B. Date Issued: C. Initial Response Due: 

1.2. Company Name: 

1.4. Contact Person: 

1.3. Address: 

1.5. Chemical Info: A. CAS #: B. Chemical Name: C. Company #(s): 

PART 2 Recipient’s Initial Response: (Please refer to the Order for more information about response options, as well as detailed 

instructions on how to comply with the Order.) 

 2.1. I will generate new data or am citing/submitting existing data. 

For each assay, check the appropriate box in the following table and follow the Order instructions to attach the data and/or required documentation. 

A. I will generate new data. 

B. I am citing existing data and/or other scientifically relevant information. 

C. I am submitting existing data and/or other scientifically relevant information. 

D. I am entering (or offering to enter) into an agreement to form a Consortium to respond to the Order. The Consortium must provide a separate initial 

response within 150 calendar days from issuance of the Order (see Initial Response Form for Consortium at http://www.epa.gov/endo/.) 

Assays: A B C D Required documentation is attached. 

2.1.1. Amphibian Metamorphosis (Frog)     

2.1.2. Androgen Receptor Binding (Rat Prostate)     

2.1.3. Aromatase (Human Recombinant)     

2.1.4. Estrogen Receptor Binding     

2.1.5. Estrogen Receptor Transcriptional Activation (Human Cell Line (HeLa-9903))     

2.1.6. Fish Short-term Reproduction     

2.1.7. Hershberger (Rat)     

2.1.8. Female Pubertal (Rat)     

2.1.9. Male Pubertal (Rat)     

2.1.10. Steroidogenesis (Human Cell Line – H295R)     

2.1.11. Uterotrophic (Rat)     

 2.2. I am citing and/or submitting other scientifically-relevant information that I believe can be used to satisfy all of the 

Order.  Required documentation is attached.

 2.3. I am not subject to the Order.  Required documentation is attached. 

 2.4. I do not, or will not continue, to manufacture or import this chemical.  Required documentation is attached.

PART 3 

3.1. Certification. I certify that the statements made on this form and all attachments are true, accurate and complete. I acknowledge that 

any knowingly false or misleading statement may be punishable by fine or imprisonment or both under applicable law. 

3.2. Company’s Authorized Representative: 3.3. Date: 

Name and Title (Please Print or Type): 

Email address: 

Signature: 

3.4. Phone Number: 

Part 4 

Submit Completed Form Using One of these Methods: 

Mail To: Document Control Office (7407M), Office of Pollution Prevention and Toxics (OPPT), U.S. EPA, 1200 Pennsylvania Ave. NW, 

Washington, D.C. 20460-0001. 

Deliver To: OPPT Document Control Office (DCO), EPA East Bldg., Rm. 6428, U.S. EPA, 1201 Constitution Ave. NW, Washington, D.C. 

20004. [Deliveries are only accepted from 8:30 a.m. to 4 p.m., Monday through Friday, excluding legal holidays.]

EPA Form No. 6300-05-SDWA 

DRAFT